Clark County Rehabilitation & Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Owen, Wisconsin.
- Location
- W4266 County Highway X, Owen, Wisconsin 54460
- CMS Provider Number
- 525403
- Inspections on file
- 27
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Clark County Rehabilitation & Living Center during CMS and state inspections, most recent first.
The facility did not ensure all staff received required training on abuse, neglect, exploitation, and dementia care, as evidenced by missing or incomplete education records for several staff members and confirmation from the DON that some new hires and casual staff had not completed necessary training. This deficiency has the potential to affect all residents.
The facility failed to follow its abuse prevention and reporting policies after two residents were subjected to inappropriate physical restraint and medication administration, and allegations of abuse were not reported to the state agency or law enforcement. Staff involved continued to work after the incidents, required notifications and investigations were not completed, and staff training on abuse prevention was inconsistent and inadequately documented.
A resident with severe cognitive impairment and a court-appointed guardian was involved in a substantiated abuse incident. Despite facility policy and the resident's care plan requiring notification, the guardian was not informed of the incident or the investigation findings. The DON could not provide documentation of any such notification, and the guardian confirmed she was unaware of the event.
Staff used physical force to administer court-ordered psychotropic medications to a resident with severe cognitive impairment, holding the resident's arms and face despite the absence of aggression. The care plan directed disguising medications in food or drink and did not authorize physical restraints, nor was there a physician order for such use. Documentation failed to reflect alternative interventions or reasons for refusals, and the incident was later substantiated through staff interviews and facility investigation.
The facility did not follow required procedures for reporting and investigating allegations of abuse involving two residents with cognitive and psychiatric conditions. In both cases, allegations were not reported to the State Agency or law enforcement as required, and staff decisions were influenced by prior unfounded reports and concerns about late reporting.
A resident with cognitive and psychiatric diagnoses was the subject of an abuse allegation reported by a family member to law enforcement. Although police visited the facility and staff notified supervisory and protective parties, no investigation into the abuse allegation was conducted, contrary to facility policy. The DON stated that prior similar allegations were unfounded and did not believe this report required investigation.
A resident with multiple psychiatric diagnoses received prescription medications administered by a CNA, who had not completed medication administration training, using physical assistance and under direct RN supervision. This practice was contrary to facility policy, which restricts medication administration to licensed staff, and resulted in a deficiency.
Three cognitively intact residents with significant medical conditions repeatedly voiced concerns about staff shortages, long call light response times, and overheard staff conversations in resident council meetings, but did not receive timely updates or follow-up from administration or staff, contrary to facility policy. Interviews confirmed a lack of formal process for addressing and communicating actions taken on these concerns.
Two residents with cognitive impairment were involved in separate incidents of verbal and physical abuse, including one resident being threatened and another being struck in the face by a peer. Both incidents resulted in injury and were confirmed by the DON as abuse.
Two residents, both cognitively intact, were involved in a physical altercation after a verbal dispute. Although the facility's policy required a thorough investigation including resident statements, staff did not interview other residents or take further investigative steps, and the DON considered the event isolated, resulting in an incomplete investigation.
A resident with a history of chronic suicidal ideation expressed a desire to kill herself, but CNAs failed to follow the care plan by not notifying nursing staff or providing required supervision. Instead, the resident was left alone in her room, and the incident was not documented in the progress notes or communicated to the nurse or Nurse Care Coordinator. The care plan's interventions, including immediate assessment and one-to-one supervision, were not implemented.
Two residents at risk for falls were subjected to the use of multiple alarms without consistent implementation of non-alarm interventions or a documented plan to reduce alarm use. Despite facility policy requiring short-term alarm use and regular review, both residents had several alarms in place simultaneously, with incomplete assessments and missing documentation of alternative strategies. Alarms failed to prevent falls, and care plan interventions such as gait belt use were not consistently followed.
A resident's right to privacy was violated when facility staff opened their mail without permission. The resident, who is cognitively intact and a registered sex offender, had previously signed a waiver during probation allowing mail to be opened, but this probation ended years ago. Despite this, the facility continued the practice without a current waiver, contrary to their policy on mail privacy.
The facility did not conduct annual performance reviews for CNAs, affecting three CNAs and potentially impacting all 147 residents. The HR Manager confirmed the absence of a system for conducting these reviews.
A facility failed to report a resident-to-resident altercation and submit the required investigation within the stipulated timeframe. A resident with dementia and behavioral issues attempted to take candy from another resident, resulting in a willful slap. Despite the care plan's interventions, the incident occurred, and the DON acknowledged it should have been reported as willful misconduct.
The facility failed to provide written transfer notices to two residents who were hospitalized. One resident, who was cognitively intact, requested a hospital transfer due to a fever but did not receive a written notice. Another resident with multiple diagnoses was also transferred without a written notice. The DON confirmed that the facility does not issue such notifications.
A resident with Huntington's disease and pneumonitis required the head of the bed to be elevated during and after tube feeding, as per their care plan. However, a surveyor observed that the resident was positioned flat during feeding, contrary to the care plan. RN C acknowledged the oversight and adjusted the bed after being prompted. Discussions with RN D and the DON confirmed the expectation to follow the care plan, highlighting a deficiency in care implementation.
A facility failed to provide adequate supervision and safety measures for two residents. One resident, with dementia and seizure disorder, experienced falls due to improperly placed chair alarms. Another resident, with behavioral issues, was involved in an altercation due to insufficient 1:1 supervision by a new CNA. The incidents highlight lapses in following care plans and staff training.
The facility did not follow professional standards for food service safety by transporting uncovered food items to residents' rooms. CNAs were observed carrying trays with uncovered cake and drinks to three residents, contrary to the facility's policy requiring all food to be covered during transport. The Director of Hospitality acknowledged that food and drinks should be covered when leaving the dining area.
A facility failed to ensure a resident received a pneumococcal vaccine. The resident, with severe cognitive impairment and chronic conditions, was admitted without proper immunization review. The Infection Preventionist and RN could not provide proof of vaccination or a clear process for residents transferring between units, leading to the oversight.
A resident developed a stage 2 pressure injury on the coccyx, which healed over a month later. The facility failed to update the resident's care plan or repositioning schedule to prevent further pressure injuries, despite the resident's immobility and incontinence. Observations showed the resident was seated in a wheelchair for extended periods without repositioning, and staff were unaware of necessary changes to the care plan.
The facility failed to timely report an allegation of sexual abuse involving a resident with multiple diagnoses. A family member reported the allegation to a nurse, but it was not reported to the State Agency or police until several days later, violating the requirement to report within 2 hours.
Failure to Ensure Staff Training on Abuse, Neglect, Exploitation, and Dementia Care
Penalty
Summary
The facility failed to ensure that all staff received required training on abuse, neglect, exploitation, and dementia care, as outlined in its own policy. The policy states that staff and volunteers must receive education on resident mistreatment, neglect, abuse, exploitation, and misappropriation of property upon hire and annually thereafter. However, review of staff education records revealed that one CNA did not have documented abuse education training, and another CNA's annual training was missed due to their casual employment status. Additionally, the RN's training was not up to date. Interviews with staff and the Director of Nursing (DON) confirmed that there were lapses in the completion and monitoring of required training. The DON acknowledged that new hire training was not completed for at least one CNA before they began working with residents and that there may be other staff with lapses in annual training due to the transition to a new tracking system. These deficiencies have the potential to affect all 134 residents in the facility.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent and respond to abuse, neglect, and misappropriation of resident property. In one incident, a certified nursing assistant (CNA) was instructed to physically restrain a resident while another CNA administered medication, which involved holding the resident's arms and face and forcibly giving medication. This incident was not immediately reported to the Director of Nursing (DON) or the Nursing Home Administrator, and the accused staff continued to work in the facility for several days after the incident before it was reported. The facility did not submit a required facility-reported incident to the state agency for two separate abuse allegations, nor did it report the abuse to law enforcement or notify the resident's representative. Additionally, a full investigation into the allegations of abuse for two residents was not completed, and there was a lack of documentation regarding notification of the resident's representative. The report also details that staff education on abuse, neglect, mistreatment, and misappropriation of resident property was not consistently completed upon hire or annually. One CNA did not have recorded abuse education training, and the system for ensuring all staff received required training was inadequate, relying only on nurse clinical coordinators to monitor completion. Signed memorandums for re-education after the incident did not include all staff signatures and did not cover the full scope of the abuse policy, such as ensuring resident safety, reporting to state agencies, and law enforcement notification. The DON acknowledged that some staff had lapses in annual training and that a new system for tracking training was still being developed. In another incident, law enforcement was contacted by a resident's family member regarding an allegation of abuse. Although law enforcement visited the facility, the facility did not submit a facility-reported incident to the state agency. The DON stated that the allegation was not reported or investigated because it was believed to be unfounded due to previous similar reports. The facility's failure to report, investigate, and document these incidents, as well as to ensure staff were properly trained, represents a breakdown in the implementation of its abuse prevention policies and procedures.
Failure to Notify Guardian of Abuse Allegation and Investigation Findings
Penalty
Summary
The facility failed to notify the legal guardian of a resident with severe cognitive impairment about an allegation of abuse and the subsequent investigation findings. The resident, who had diagnoses including anxiety disorder, depression, personality disorder, and unspecified psychosis, was under a court-appointed permanent guardianship due to incompetency and was subject to an involuntary order to treat with psychotropic medications. The resident's care plan specifically required that the physician and guardian be notified of any change in condition, including medication non-compliance. Despite this, when an allegation of staff abuse involving the resident was reported and substantiated, there was no documentation that the guardian was informed of either the incident or the investigation results. During the survey, the guardian confirmed in an interview that she had not been notified of the incident or the findings, and this was the first time she was hearing about the event. The facility's policy required that the resident or their representative be informed of any incident and the results of investigations. The DON stated she believed the guardian had been notified but could not provide documentation to support this. The lack of notification to the guardian was confirmed through record review and interviews.
Inappropriate Use of Physical Restraints During Medication Administration
Penalty
Summary
Facility staff failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. The facility's policy requires that physical restraints only be used after a comprehensive assessment, as a last resort, and with a physician order and consent from the resident's legal representative. However, staff used physical force to administer oral psychotropic medications to a resident with severe cognitive impairment and a history of psychiatric disorders, including anxiety, depression, and psychosis. The resident had a court order for involuntary medication, and the care plan specified disguising medications in food or drink, but did not include the use of physical restraints for medication administration. On two occasions, staff members held the resident's arms and face to forcibly administer medications by mouth, despite the resident not being physically aggressive but attempting to push the medications away. One CNA held the resident's hands above his head and then at his sides, while another held the resident's face to open his mouth, and a nurse supervised the process. Staff justified their actions by citing the court order for medication, but there was no physician order for the use of physical restraints, nor was this intervention included in the care plan. The medication administration record did not document reasons for refusals or alternative interventions attempted. The incident was reported by a CNA who expressed concern about the use of force, and an internal investigation substantiated the allegation of inappropriate use of physical restraints. The facility's documentation and staff interviews confirmed that the use of physical force occurred during medication administration, in violation of facility policy and regulatory requirements. The resident's care plan and physician orders did not authorize the use of physical restraints for this purpose.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of alleged physical abuse in accordance with federal and state requirements. In two separate cases, allegations of abuse involving two residents were not reported to the State Agency or local law enforcement as required. In the first case, local law enforcement notified the facility of an abuse allegation concerning a resident with cognitive impairment and psychiatric diagnoses, but the facility did not submit a Facility Reported Incident (FRI) to the State Agency. The Director of Nursing (DON) stated that due to previous unfounded reports from the resident and his sister, the facility did not believe the allegation warranted reporting or investigation. In the second case, a resident with psychiatric and cognitive diagnoses was subjected to physical restraint and threats by staff during medication administration, as witnessed by a CNA. The CNA reported the incidents to a nurse manager, who acknowledged the behavior as abuse but did not immediately escalate the report to the DON. When the DON was eventually notified, an internal investigation was conducted, and the staff member involved was terminated. However, the facility did not report the allegation to the State Agency or local law enforcement, and the DON stated the decision was made not to report because the notification was delayed and they anticipated being cited for late reporting.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident with a history of mild cognitive impairment, personality disorder, delusional disorders, unspecified psychosis, and depression. On the date in question, the resident's sister contacted local law enforcement to report concerns that the resident was being abused and did not feel safe. Law enforcement arrived at the facility to address the allegation. Facility documentation showed that staff were aware of the report and notified relevant parties, including the resident's guardian, Adult Protective Services social worker, and supervisory staff. However, there was no documentation of any investigation into the abuse allegation as required by facility policy. During an interview, the Director of Nursing stated that both the resident and the resident's sister had made multiple prior unfounded allegations of abuse and, as a result, did not believe this particular allegation warranted reporting or investigation. The facility's policy requires that all reports of abuse, neglect, or mistreatment be promptly and thoroughly investigated, but this was not followed in this instance. No root cause investigation or analysis was documented for the reported allegation.
Unlicensed Staff Administered Prescription Medications
Penalty
Summary
Prescription medications for one resident were administered by a Certified Nursing Assistant (CNA), contrary to facility policy and regulatory requirements. The resident had diagnoses including anxiety disorder, depression, personality disorder, and unspecified psychosis, and had physician orders for Haloperidol Lactate and Valium. Facility documentation and interviews revealed that the CNA administered these medications using food, ice cream, and a syringe, with another staff member holding the resident's hand and the CNA holding the resident's chin to squirt the medication into the resident's mouth. This administration was performed under the direct supervision of a Registered Nurse (RN), but the CNA had not completed any medication administration training or competency evaluation. Facility policies explicitly state that only licensed nurses or nurse technicians are permitted to administer medications, and that CNAs may not administer medications except for applying topical creams to unbroken skin or providing oral care with mouthwashes. Despite this, the Director of Nursing (DON) confirmed that it was common practice for CNAs to administer medications under direct nurse supervision, without additional training or competency assessment. This practice was in direct violation of both facility policy and regulatory standards, resulting in the identified deficiency.
Failure to Provide Timely Updates on Resident Council Concerns
Penalty
Summary
The facility failed to provide timely updates to residents regarding concerns raised during resident council meetings, as required by their own policy. Specifically, three cognitively intact residents with various medical conditions, including multiple sclerosis, quadriplegia, and coronary artery disease, reported that issues such as staff discussing other residents, insufficient staffing, and long call light response times were repeatedly brought up in meetings. Despite these concerns being documented in the Resident Voice Minutes over several months, residents stated they did not receive follow-up or updates from administration or staff about actions taken to address these issues. Interviews with residents and staff revealed that the Director of Nursing did not regularly attend resident council meetings and was unaware of when they occurred. The Activity Director did not document follow-up conversations with residents, and the Case Manager confirmed there was no formal process for following up on concerns voiced in resident council. Residents expressed frustration that their concerns, particularly about staffing and call light response times, were not addressed or communicated back to them, impacting their daily routines such as timely access to breakfast and coffee.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse between residents, as evidenced by two separate incidents involving three residents. In the first incident, a resident with severe cognitive impairment and dementia (BIMS score 3/15) was involved in a verbal altercation with another resident who was cognitively intact (BIMS score 15/15) and had a history of behavioral symptoms. The cognitively intact resident was observed yelling threatening statements, while the cognitively impaired resident pushed a medication cart toward him, resulting in the latter losing balance and sustaining a bruise and abrasion after falling. In the second incident, a resident with moderate cognitive impairment and dementia (BIMS score 9/15) was found hitting the same severely cognitively impaired resident in the face. The aggressor believed the other resident was in his bed, and this event was discovered when a CNA responded to the victim's calls for help. The incident was reported to law enforcement, and the aggressor had a recent medication change that may have contributed to impulsive behavior. Both incidents were confirmed by the DON as instances of physical and verbal abuse between residents.
Failure to Conduct Thorough Investigation After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation following an alleged abuse incident involving two residents. According to the facility's policy, when an incident or suspected incident of abuse is reported, the investigation should include resident statements. In this case, a resident-to-resident altercation occurred when one resident struck another in the head with a remote after a verbal exchange. Both residents involved were cognitively intact, as indicated by their Brief Interview Mental Score (BIMS) of 15 out of 15. Law enforcement was called, and the residents were separated immediately following the incident. Despite the policy requirements, the investigation did not include interviews with other residents or further investigative steps beyond the immediate response. Staff interviews revealed that no one was instructed to interview other residents or provide additional education to staff. The DON confirmed that no further investigation was conducted, believing the event to be isolated. This lack of a comprehensive investigation did not align with the facility's policy and left the incident insufficiently examined.
Failure to Implement Care Plan for Resident Expressing Suicidal Ideation
Penalty
Summary
A deficiency occurred when staff failed to implement a resident's care plan interventions after the resident expressed suicidal ideation. The resident, who had a history of chronic suicidal ideation, mild cognitive impairment, legal blindness, abnormal gait, osteoarthritis, and anxiety disorder, repeatedly stated she wanted to kill herself. Despite these statements, Certified Nursing Assistants (CNAs) did not notify the nurse on duty or the Nurse Care Coordinator as required by the care plan. The care plan specifically directed staff not to leave the resident alone, to immediately notify nursing staff, and to provide one-to-one supervision until a nurse could assess the resident's safety and implement further interventions. On the day of the incident, the resident was found alone in her room, repeatedly calling for help and expressing a desire to die. Staff present on the unit acknowledged that the resident often made such statements and described their response as attempting to calm her and documenting the behavior, but did not escalate the situation to nursing staff for assessment. The CNAs reported that when the resident was disruptive, she was placed in her room alone to avoid agitating other residents, contrary to the care plan's instructions. There was no documentation in the progress notes of the resident's suicidal statements on the day in question, and neither the nurse on duty nor the Nurse Care Coordinator were informed of the incident. Both confirmed in interviews that they had not been notified and that the care plan should have been followed, including immediate assessment and supervision. The Director of Nursing also confirmed that the care plan's directives were not implemented as required.
Failure to Provide Non-Alarm Interventions and Proper Alarm Reduction for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that two residents at risk for falls were consistently provided with non-alarm interventions before and after the implementation of multiple alarms. Both residents were subjected to the use of several alarms simultaneously—one with five alarms and the other with four—without a documented plan to reduce alarm use or assess the necessity of concurrent alarms. The facility's own policies required that alarms be used on a short-term basis and that the interdisciplinary team review the potential for eliminating alarms while developing other strategies, but there was no evidence that these steps were followed. Additionally, alarm assessments were incomplete, with missing documentation and blank sections regarding alternative strategies and justification for alarm use. For one resident with mild cognitive impairment, legal blindness, abnormal gait, and anxiety disorder, alarms were used extensively, including a motion sensor, chair alarm, bed alarm, and a Tabs alarm. Observations revealed that the alarms were loud and disruptive, and the resident was unaware of the source of the noise. Despite the use of multiple alarms, the resident experienced several falls, some of which occurred when alarms failed to prevent self-transfers or were not in place. The care plan required the use of a gait belt for all transfers, but this was not consistently followed, and there was no documentation that nursing staff were notified when the resident refused the gait belt, as required by the care plan. For the second resident, who had dementia and a history of wandering and falls, multiple alarms were also used, including a bed alarm, chair alarm, motion sensor, and wander/elopement alarm. The care plan and assessments did not document the use of alternative interventions or a reduction plan for alarm use. There was also a lack of documentation in progress notes and social services notes regarding the discussion or justification of alarm use. Staff interviews confirmed that alarms were implemented based on the resident's history of falls, but there was no admission assessment or documentation of other options considered prior to alarm use.
Violation of Resident's Mail Privacy
Penalty
Summary
The facility failed to ensure a resident's right to privacy was maintained when receiving mail. A resident, identified as R2, who is cognitively intact and able to communicate effectively, reported that facility staff opened their mail without permission. This practice began approximately five months prior to the survey, coinciding with R2's ordering of adult movies. R2, a registered sex offender with a history of child pornography, had previously signed a waiver in 1998 allowing mail to be opened during probation, which ended in 2002. Despite the end of probation, the facility continued to open R2's mail without a current waiver or consent. Interviews with facility staff, including a Certified Nursing Assistant, Nursing Care Coordinator, and Social Services staff, confirmed the practice of opening R2's mail. The Nursing Care Coordinator stated that mail is typically delivered unopened, but R2's mail is treated differently due to their criminal history. The Director of Social Services and a Social Worker acknowledged the challenges since R2's admission and confirmed that the waiver signed during probation was no longer valid. The facility's policy on mail distribution emphasizes residents' rights to privacy and assistance with mail upon request, which was not adhered to in R2's case.
Lack of Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received a performance review every 12 months, affecting three out of five CNAs reviewed. Specifically, CNAs H, I, and J, who have been employed since 06/14/22, 07/13/17, and 08/15/22 respectively, did not have documented annual performance reviews. Upon inquiry, the Human Resources Manager confirmed that the facility did not have a system in place to conduct these reviews, and no performance reviews had been completed for any staff. This deficiency had the potential to impact all 147 residents residing in the facility.
Failure to Report Resident Altercation and Submit Investigation
Penalty
Summary
The facility failed to report an incident of potential misconduct to the state agency immediately upon learning of the incident and did not submit the required 5-day investigation report within the stipulated timeframe. This deficiency was identified during a surveyor's review of an altercation involving a resident with dementia and behavioral issues. The resident, who has a history of short-term and long-term memory problems, as well as physical and verbal behavioral symptoms, was involved in an incident where they attempted to take candy from another resident, resulting in a willful slap. This action was deemed potentially harmful and should have been reported as per the facility's policy and state regulations. The resident's care plan, which was initiated to manage psychopharmacological medication and behavior, included interventions to prevent altercations with peers. Despite these measures, the incident occurred, and the Director of Nursing acknowledged that the altercation should have been reported as it was considered willful. The failure to report the incident and submit the investigation in a timely manner highlights a lapse in adhering to the facility's abuse, neglect, mistreatment, and misappropriation of resident property policy and procedure.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide proper notification of transfer to two residents, R56 and R127, who were hospitalized. R56, who was cognitively intact and capable of making decisions, was transferred to the hospital after experiencing a fever and requesting the transfer. However, R56 was not given a written notice of the transfer, which is a requirement. During an interview, the Director of Nursing (DON) admitted that the facility does not provide written notifications to residents or their representatives when transferring them to the emergency room. Similarly, R127, who had diagnoses including paranoid schizophrenia, type 2 diabetes, dementia, and anxiety, was transferred to the hospital without receiving a written notice of the transfer. The surveyor was unable to find any documentation of a discharge/transfer notice for R127's hospitalization. When asked, the DON confirmed that the facility did not issue a transfer notice for R127's hospital transfer. This lack of proper notification is a deficiency in the facility's compliance with regulations regarding resident transfers.
Failure to Implement Care Plan for Resident with Huntington's Disease
Penalty
Summary
The facility failed to implement the comprehensive, person-centered care plan for a resident diagnosed with Huntington's disease and pneumonitis due to inhalation of food and vomit. The care plan specified that the resident required the head of the bed (HOB) to be elevated 45 degrees during and thirty minutes after tube feeding to accommodate their condition. However, during an observation by a surveyor, it was noted that the resident was positioned flat with their head resting at pillow height, contrary to the care plan's requirements. This position was not adjusted during the tube feeding administration by Registered Nurse (RN) C. Upon inquiry by the surveyor, RN C acknowledged that the bed was not at the required angle and subsequently adjusted it. Further discussions with the supervisor, RN D, and the Director of Nursing (DON) B confirmed that the expectation was for the nurse to ensure the bed was elevated to 45 degrees before starting the procedure, especially given the resident's condition that affects gastric motility and predisposes them to emesis. The failure to adhere to the care plan's directives constituted a deficiency in the care provided to the resident.
Inadequate Supervision and Safety Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, R34 and R100. R34, who has dementia and a seizure disorder, was identified as high risk for falls. Despite having a care plan that included the use of a chair sensor alarm, the facility's fall-root cause analysis revealed that the alarm was either inappropriately placed or not under the resident during two separate falls. This indicates a failure to follow the care plan and ensure the safety interventions were in place. R100, diagnosed with dementia with agitation and other behavioral issues, was supposed to have 1:1 supervision to maintain safety. However, during an incident, a new CNA, unfamiliar with R100, was unable to prevent the resident from engaging in a physical altercation with another resident. The CNA was covering for a more experienced CNA on break, and the lack of proper training and supervision led to the incident. The Director of Nursing acknowledged the expectation for the CNA to intervene before the altercation occurred, highlighting a lapse in staff training and supervision protocols.
Uncovered Food Transported to Residents' Rooms
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not covering food items during transportation to residents' rooms. The facility's policy, titled 'Dining - Meal Service,' mandates that all food must be covered when transported through the unit. However, during an observation, Certified Nursing Assistants (CNAs) were seen carrying trays with uncovered cake and drinks to residents' rooms. This occurred with three residents, who were eating in their rooms, and the uncovered items were transported down the hallway, potentially leading to contamination. The Director of Hospitality, responsible for kitchen and dining services, confirmed that all food and drinks should be covered when leaving the dining area, indicating a lapse in following the established policy.
Failure to Administer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that vaccinations were reviewed, offered, or administered for one of the sampled residents, identified as R23. The resident was admitted with severe cognitive impairment and diagnoses of chronic cough and obstructive sleep apnea. During the survey, the Infection Preventionist was unable to provide immunization information for R23, directing the surveyor to another nurse. When the surveyor followed up with Registered Nurse F, it was revealed that there was no proof that R23 had been offered or received a pneumococcal vaccine. The process for screening and administering immunizations upon admission was questioned, and RN F admitted that there was no clear process in place for residents who transferred between units. This lack of a systematic approach led to the oversight in ensuring R23 received the necessary pneumococcal vaccination, as there was no documentation or evidence of the vaccine being offered or administered. The deficiency highlights a gap in the facility's immunization protocol, particularly for residents transferring between units.
Failure to Update Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to provide care and treatment based on professional standards of practice for a resident at risk for pressure injuries. The resident, identified as R4, developed a new stage 2 pressure injury on the coccyx, which was noted on June 1, 2024, and healed by July 9, 2024. Despite the development of this pressure injury, the facility did not update R4's care plan or repositioning schedule to align with current standards of practice, which contributed to the deficiency. R4's care plan, initiated in December 2022, identified the potential for pressure ulcer development due to immobility and incontinence. However, no changes were made to the interventions following the development of the pressure injury. The care plan included interventions such as educating caregivers on skin breakdown causes, following facility protocols, and monitoring skin status. Despite these interventions, the care plan was not revised to address the new pressure injury or to adjust R4's repositioning schedule. Observations by the surveyor revealed that R4 was seated in a wheelchair for extended periods, sometimes exceeding four hours, without repositioning. The CNA responsible for R4's care was unaware of any changes to the repositioning schedule following the pressure injury's development. The Nurse Care Coordinator acknowledged that R4's care plan should have been updated to include more frequent repositioning, ideally every two hours, to prevent further pressure injuries. This oversight in care planning and execution led to the deficiency noted in the report.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to develop and implement policies and procedures for ensuring the timely reporting of a reasonable suspicion of a crime, specifically an allegation of sexual abuse. The incident involved a resident with diagnoses including congestive heart failure, anxiety disorder, major depressive disorder, type 2 diabetes, and heart failure. On 03/08/24, a family member reported to a registered nurse that the resident had alleged an Amish man was having his way with them. However, this allegation was not reported immediately as required by law. The Director of Nursing acknowledged that the report should have been made sooner, but it was not submitted to the State Agency until 03/14/24, and the police were also not notified until that date. This delay in reporting violated the requirement to report such allegations within 2 hours. The facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property states that reports of abuse are to be promptly and thoroughly investigated, which was not adhered to in this case.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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